CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Commercial Drug Formulary — Outpatient Pharmacy Coverage, Prior Authorization, Step Therapy, and Exception Processes

Defines the outpatient pharmacy formulary, coverage rules, prior authorization, step therapy, and exception/appeal processes for Neighborhood Health Plan of Rhode Island commercial members and their providers.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCommercial Drug Formulary — Outpatient Pharmacy Coverage, Prior Authorization, Step Therapy, and Exception Processes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFor drugs marked 'PA', prescribers must call or fax the Neighborhood Pharmacy Department to obtain prior authorization and provide required clinical information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlyP&T Committee meeting frequency

1-855-321-9244Customer Service

1-401-427-8200PA phone

1866-423-0945PA fax

365 daysMax supply for 'C' items

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Coverage rules and exclusions

General Coverage and Exclusions

Formulary coverage applies to outpatient drugs and excludes experimental, cosmetic, and nonlisted products; some OTCs may be covered with a prescription.

General provisions: Coverage applies only to outpatient drugs; drugs not listed on the formulary are not covered; cosmetic uses are excluded; experimental or investigational uses are excluded; some OTC products are covered with a prescription.

Based on Formulary general provisions in the Formulary Coverage Limitations and Experimental Drugs sections.

Non‑Formulary Exception Criteria

Non‑formulary medications may be approved when the prescriber documents one of the following.

Exception criteria (any one met): a) All formulary products are contraindicated for the patient; b) the patient has failed an appropriate trial of formulary or related agents; c) formulary choices are not suited for the present patient care need and the requested drug is required for patient safety; d) use of a formulary drug may provoke an underlying condition detrimental to patient care.

Prescriber must provide supporting clinical information when requesting non-formulary coverage; requests are evaluated by Neighborhood pharmacy and medical staff.

The formulary excludes drug products that are determined to be experimental or investigational and excludes drug products used for cosmetic purposes. Coverage applies only to outpatient drugs; drugs not listed on the formulary are not covered. Some over‑the‑counter products may be covered when a written prescription is provided.

Any drug product or any use of a drug that is determined to be experimental, investigational, or an off‑label use is not covered. The experimental status or use will be determined by the PBM’s Pharmacy & Therapeutics Committee using current medical literature.

What providers must do (PA, ST, documentation, denials)

Prior Authorization

Prior Authorization required

Drugs listed with PA on the Formulary require Prior Authorization before coverage will be provided at the pharmacy. To obtain PA, a prescriber or prescriber's representative may: fax a completed Prior Authorization Request to the Neighborhood Pharmacy Department at 1-866-423-0945, or contact the Neighborhood Pharmacy Department pharmacist at 1-401-427-8200 and provide all necessary clinical information. Each request is reviewed on individual patient need against PBM/P&T criteria.

PA drugs require prior authorization
Fax: 1-866-423-0945
Phone: 1-401-427-8200

Step Therapy

Step Therapy requirement and exception

Drugs listed with ST require Step Therapy — the member must try specified formulary alternatives before the requested medication is covered. If the required formulary products are inappropriate or cannot be used by the member, the provider may request an exception to Step Therapy by submitting clinical rationale and documentation.

Key terminology

Prior Authorization (PA)

DefinitionDrugs listed with 'PA' require Prior Authorization — the drug requires approval before coverage.

ActionPrescriber or authorized representative must fax or call Neighborhood Pharmacy Department to obtain approval and supply requested clinical information.

ReferenceSee Formulary Requirements/Limits column for PA designation details.

Quantity Limit (QL)

Definition'QL' indicates a Quantity Limit — a restriction on the amount of medication that may be dispensed per fill.

ScopeQuantity limits are shown in the Formulary Requirements/Limits column and apply to covered outpatient drugs.

Step therapy requirements

Step Therapy Requirement	Required Formulary Alternatives / Actions	Exception Pathway
Drugs labeled 'ST' — member must try specified formulary products before the requested medication will be covered.	Member must complete a trial of the formulary alternatives as listed on the Formulary prior to initiation of the non‑formulary or non‑preferred agent. Trials should follow the sequence and agents specified by the plan.	Provider may request a Step Therapy exception when required formulary products are inappropriate or cannot be taken by the member. Exception requests must include clinical rationale (e.g., contraindication, prior treatment failure, or safety/patient‑specific need) and be submitted to the Neighborhood Pharmacy Department via fax or phone for review.

Quantity limit rules

Drugs Marked 'C' — Quantity Limit

Allowed supplyDrugs marked 'C' allow dispensing of up to 365 days' supply in a single retail pharmacy fill.

Where notedThe 'C' designation is displayed in the Formulary Requirements/Limits column for eligible drugs.

Intended useFacilitates extended‑supply dispensing when clinically appropriate and permitted by the benefit.

Formulary governance and scope

The formulary is a managed list of outpatient medications maintained and reviewed by the Pharmacy & Therapeutics (P&T) Committee. The P&T Committee evaluates safety, efficacy, comparative benefit, cost/outcomes, duplication, and appropriate restrictions when selecting agents for the formulary. The Committee also determines whether a product or a proposed use is experimental and therefore excluded from coverage based on current medical literature.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyCommercial Drug Formulary — Outpatient Pharmacy Coverage, Prior Authorization, Step Therapy, and Exception Processes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFor drugs marked 'PA', prescribers must call or fax the Neighborhood Pharmacy Department to obtain prior authorization and provide required clinical information.

SourceLink

On This Page

ST = Step Therapy; trial of alternatives required
Provider may request Step Therapy exception with clinical justification

Documentation Required

Information to include with Non‑Formulary/PA requests

When requesting coverage for a non‑formulary medication or a PA/Step Therapy exception, prescribers should provide clinical documentation addressing why formulary products are not suitable. Information to include: diagnosis and indication, prior medication history and reasons for failure or intolerance of formulary/related agents, clinical rationale that formulary options are contraindicated or would be detrimental to patient care, and any safety reasons why the selected drug is required.

Document prior trials of formulary or related agents and reasons for discontinuation
State contraindications or safety concerns with formulary alternatives
Include diagnosis, indication, and supporting clinical notes or test results

Denial Risk

Denial triggers and process

If a request does not meet exception or PA criteria, Neighborhood will provide the prescriber the rationale and available formulary alternatives and may refer the prescriber to the Neighborhood Medical Director or Physician Reviewer for further discussion. Denials will be communicated verbally when discussed and followed by written notice to both prescriber and member outlining the reason for denial, applicable benefit or clinical guideline, supporting documentation available for review, and instructions for filing an appeal. Members may also contact Customer Service to register a complaint or inquiry and will be informed of appeal rights.

Prescriber will receive the rationale and recommended formulary alternatives
Medical Director/Physician Reviewer will assess medical necessity and discuss denials with prescriber
Written denial notices to prescriber and member will include reasons, guidelines, and appeal instructions
Members may contact Customer Service for inquiries and appeal information

PurposeLimits promote appropriate use and help ensure safe, cost‑effective dispensing quantities.

Step Therapy (ST)

Definition'ST' denotes Step Therapy — coverage requires evidence that specified formulary alternatives were tried and failed before the requested medication is covered.

ExceptionProviders may request exceptions when required alternatives are inappropriate or cannot be taken by the member.

'C' Designation — Maximum Retail Supply

Designation meaningDrugs listed as 'C' may be dispensed at retail pharmacy for up to 365 days' supply in one fill.

ApplicationApplies to outpatient retail pharmacy fills as indicated in the Formulary.

Location in Formulary'C' appears in the Requirements/Limits column for applicable drugs.